NURSING CONCEPTUAL MODELS

Unitary Human Being

 Martha Elizabeth Rogers (1914 – 1994)

Description
 Rogers’ theory defined Nursing as “an art and science that is humanistic and
humanitarian. It is directed toward the unitary human and is concerned with
the nature and direction of human development. The goal of nurses is to
participate in the process of change.”
 According to Rogers, the Science of Unitary Human Beings contains two
dimensions: the science of nursing, which is the knowledge specific to the
field of nursing that comes from scientific research; and the art of nursing,
which involves using the science of nursing creatively to help better the life
of the patient.

Assumptions

The assumptions of Rogers’ Theory of Unitary Human Beings are as follows: (1)
Man is a unified whole possessing his own integrity and manifesting characteristics
that are more than and different from the sum of his parts. (2) Man and
environment are continuously exchanging matter and energy with one another. (3)
The life process evolves irreversibly and unidirectionally along the space-time
continuum. (4) Pattern and organization identify the man and reflect his innovative
wholeness. And lastly, (5) Man is characterized by the capacity for abstraction and
imagery, language and thought sensation and emotion.

Major Concepts

Human-unitary human beings

A person is defined as an indivisible, pan-dimensional energy field identified by a
pattern, and manifesting characteristics specific to the whole, and that can’t be
predicted from knowledge of the parts. A person is also a unified whole, having its
own distinct characteristics that can’t be viewed by looking at, describing, or
summarizing the parts.

Health
Rogers defines health as an expression of the life process. It is the characteristics
and behavior coming from the mutual, simultaneous interaction of the human and
environmental fields, and health and illness are part of the same continuum. The
multiple events occurring during the life process show the extent to which a person
is achieving his or her maximum health potential. The events vary in their
expressions from greatest health to those conditions that are incompatible with the
maintaining life process.
Nursing
It is the study of unitary, irreducible, indivisible human and environmental fields:
people and their world. Rogers claims that nursing exists to serve people, and the
safe practice of nursing depends on the nature and amount of scientific nursing
knowledge the nurse brings to his or her practice

Scope of Nursing
Nursing aims to assist people in achieving their maximum health potential.
Maintenance and promotion of health, prevention of disease, nursing diagnosis,
intervention, and rehabilitation encompass the scope of nursing’s goals.
Nursing is concerned with people-all people-well and sick, rich and poor, young and
old. The arenas of nursing’s services extend into all areas where there are people:
at home, at school, at work, at play; in hospital, nursing home, and clinic; on this
planet and now moving into outer space.

Environmental Field
“An irreducible, indivisible, pandimensional energy field identified by pattern and
integral with the human field.”

Energy Field
The energy field is the fundamental unit of both the living and the non-living. It
provides a way to view people and the environment as irreducible wholes. The
energy fields continuously vary in intensity, density, and extent.

Subconcepts

Openness
There are no boundaries that stop energy flow between the human and
environmental fields, which is the openness in Rogers’ theory. It refers to qualities
exhibited by open systems; human beings and their environment are open
systems.

Pandimensional
Pan-dimensionality is defined as “non-linear domain without spatial or temporal
attributes.” The parameters that humans use in language to describe events are
arbitrary, and the present is relative; there is no temporal ordering of lives.
Synergy is defined as the unique behavior of whole systems, unpredicted by any
behaviors of their component functions taken separately.
Human behavior is synergistic.

Pattern
Rogers defined the pattern as the distinguishing characteristic of an energy field
seen as a single wave. It is an abstraction and gives identity to the field.
Principles of Homeodynamics
Homeodynamics should be understood as a dynamic version of homeostasis (a
relatively steady state of internal operation in the living system).
Homeodynamic principles postulate a way of viewing unitary human beings. The
three principles of homeodynamics are resonance, helicy, and integrality.

Principle of Reciprocy
Postulates the inseparability of man and environment and predicts that sequential
changes in life process are continuous, probabilistic revisions occurring out of the
interactions between man and environment.

Principle of Synchrony
This principle predicts that change in human behavior will be determined by the
simultaneous interaction of the actual state of the human field and the actual state
of the environmental field at any given point in space-time.

Principle of Integrality (Synchrony + Reciprocy)

Because of the inseparability of human beings and their environment, sequential
changes in the life processes are continuous revisions occurring from the
interactions between human beings and their environment.
Between the two entities, there is a constant mutual interaction and mutual change
whereby simultaneous molding is taking place in both at the same time.

Principle of Resonancy
It speaks to the nature of the change occurring between human and environmental
fields. The life process in human beings is a symphony of rhythmical vibrations
oscillating at various frequencies.
It is the identification of the human field and the environmental field by wave
patterns manifesting continuous change from longer waves of lower frequency to
shorter waves of higher frequency.

Principle of Helicy
The human-environment field is a dynamic, open system in which change is
continuous due to the constant interchange between the human and environment.
This change is also innovative. Because of constant interchange, an open system is
never exactly the same at any two moments; rather, the system is continually new
or different.

Strengths
Rogers’ concepts provide a worldview from which nurses may derive theories and
hypotheses and propose relationships specific to different situations.
Rogers’ theory is not directly testable due to lack of concrete hypotheses, but it is
testable in principle.
Weaknesses
Rogers’ model does not define particular hypotheses or theories for it is an abstract,
unified and highly derived framework.
Testing the concepts’ validity is questionable because its concepts are
not directly measurable.

The theory was believed to be profound and was too ambitious because the
concepts are extremely abstract.

Rogers claimed that nursing exists to serve people, however, nurses’ roles were not
clearly defined.
The purpose of nurses is to promote health and well-being for all persons wherever
they are. However, Rogers’ model has no concrete definition of health state.

Conclusion
The Science of Unitary Human Beings is highly generalizable as the concepts and
ideas are not confined with a specific nursing approach unlike the usual way of
other nurse theorists in defining the major concepts of a theory.
Rogers gave much emphasis on how a nurse should view the patient. She
developed principles which emphasize that a nurse should view the client as a
whole.
Her statements, in general, made us believe that a person and his or her
environment are integral to each other. That is, a patient can’t be separated from
his or her environment when addressing health and treatment. Her conceptual
framework has greatly influenced all aspects of nursing by offering an alternative to
traditional approaches of nursing.

SELF-CARE DEFICIT THEORY

 Dorethea Elizabeth Orem (1914 – 2007)

There are instances wherein patients are encouraged to bring out the best in them
despite being ill for a period of time. This is very particular in rehabilitation settings,
in which patients are entitled to be more independent after being cared for
by physiciansand nurses. Through these, the Self-Care Nursing
Theory or the Orem Model of Nursing was developed by Dorothea
Orem between 1959 and 2001. It is considered a grand nursing theory, which
means the theory covers a broad scope with general concepts that can be applied
to all instances of nursing.

Description

 Dorothea Orem’s Self-Care Deficit Theory defined Nursing as “The act of

assisting others in the provision and management of self-care to maintain or
improve human functioning at home level of effectiveness.” It focuses on
each individual’s ability to perform self-care, defined as “the practice of
activities that individuals initiate and perform on their own behalf in
maintaining life, health, and well-being.”

 “The condition that validates the existence of a requirement for nursing in an

adult is the absence of the ability to maintain continuously that amount and
quality of self-care which is therapeutic in sustaining life and health, in
recovering from disease or injury, or in coping with their effects. With
children, the condition is the inability of the parent (or guardian) to maintain
continuously for the child the amount and quality of care that is therapeutic.”
(Orem, 1991)

Assumptions of the Self-Care Deficit Theory

 The assumptions of Dorothea Orem’s Self-Care Theory are: (1) In order to

stay alive and remain functional, humans engage in constant communication
and connect among themselves and their environment. (2) The power to act
deliberately is exercised to identify needs and to make needed judgments.
(3) Mature human beings experience privations in the form of action in care
of self and others involving making life-sustaining and function-regulating
actions. (4) Human agency is exercised in discovering, developing, and
transmitting to others ways and means to identify needs for, and make
inputs into, self and others. (5) Groups of human beings with structured
relationships cluster tasks and allocate responsibilities for providing care to
group members.

Major Concepts of the Self-Care Deficit Theory

In this section are the definitions of the major concepts of Dorothea Orem’s Self-
Care Deficit Theory:

Nursing

Nursing is an art through which the practitioner of nursing gives specialized

assistance to persons with disabilities which makes more than ordinary assistance
necessary to meet needs for self-care. The nurse also intelligently participates in
the medical care the individual receives from the physician.

Humans

Humans are defined as “men, women, and children cared for either singly or as
social units,” and are the “material object” of nurses and others who provide direct
care.

Environment

The environment has physical, chemical and biological features. It includes the
family, culture, and community.

Health

Health is “being structurally and functionally whole or sound.” Also, health is a state
that encompasses both the health of individuals and of groups, and human health is
the ability to reflect on one’s self, to symbolize experience, and to communicate
with others.

Self-Care

Self-care is the performance or practice of activities that individuals initiate and

perform on their own behalf to maintain life, health, and well-being.

Self-Care Agency

Self-care agency is the human’s ability or power to engage in self-care and is

affected by basic conditioning factors.
Basic Conditioning Factors

Basic conditioning factors are age, gender, developmental state, health state, socio-
cultural orientation, health care system factors, family system factors, patterns of
living, environmental factors, and resource adequacy and availability.

Therapeutic Self-Care Demand

Therapeutic Self-care Demand is

the totality of “self-care actions to
be performed for some duration in order to meet known self-care requisites by
using valid methods and related sets of actions and operations.”

Self-Care Deficit

Self-care Deficit delineates when nursing is needed. Nursing is required when an

adult (or in the case of a dependent, the parent or guardian) is incapable of or
limited in the provision of continuous effective self-care.

Nursing Agency

Nursing Agency is a complex property or attribute of people educated and trained

as nurses that enables them to act, to know, and to help others meet their
therapeutic self-care demands by exercising or developing their own self-care
agency.

Nursing System

Nursing System is the product of a series of relations between the persons:

legitimate nurse and legitimate client. This system is activated when the client’s
therapeutic self-care demand exceeds available self-care agency, leading to the
need for nursing.

Theories

The Self-Care or Self-Care Deficit Theory of Nursing is composed of three

interrelated theories: (1) the theory of self-care, (2) the self-care deficit
theory, and (3) the theory of nursing systems, which is further classified
into wholly compensatory, partial compensatory and supportive-educative.

Theory of Self-Care

This theory focuses on the performance or practice of activities that individuals

initiate and perform on their own behalf to maintain life, health and well-being.

Self-Care Requisites
Self-care Requisites or requirements can be defined as actions directed toward the
provision of self-care. It is presented in three categories:

Universal Self-Care Requisites

Universal self-care requisites are associated with life processes and the
maintenance of the integrity of human structure and functioning.

Developmental self-care requisites

Developmental self-care requisites are “either specialized expressions of universal

self-care requisites that have been particularized for developmental processes or
they are new requisites derived from a condition or associated with an event.”

Health deviation self-care requisites

Health deviation self-care requisites are required in conditions of illness, injury, or

disease or may result from medical measures required to diagnose and correct the
condition.

Analysis of the Self-Care Deficit Theory

There is a superb focus of Orem’s work which is self-care. Even though there is a
wide range of scope seen in the encompassing theory of nursing systems, Orem’s
goal of letting the readers view nursing care as a way to provide assistance to
people was apparent in every concept presented.
From the definition of health which is sought to be rigid, it can now be refined by
making it suitable to the general view of health as a dynamic and ever-changing
state.

The role of the environment to the nurse-patient relationship, although defined by

Orem was not discussed.

The role of nurses in maintaining health for the patient was set by Orem with great
coherence in accordance with the life-sustaining needs of every individual.

Although Orem viewed the importance of the parents or guardian in providing for
their dependents, the definition of self-care cannot be directly applied to those who
need complete care or assistance with self-care activities such as the infants and
the aged.

Strengths

 A major strength of Dorothea Orem’s theory is that it is applicable for

nursing by the beginning practitioner as well as the advanced clinicians.
 Orem’s theory provides a comprehensive basis for nursing practice. It has
utility for professional nursing in the areas of nursing practice, nursing
education and administration.
 The terms self-care, nursing systems, and self-care deficit are easily
understood by the beginning student nurse and can be explored in greater
depth as the nurse gains more knowledge and experience.
 She specifically defines when nursing is needed: Nursing is needed when
the individual cannot maintain continuously that amount and quality of
self-care necessary to sustain life and health, recover from disease or
injury, or cope with their effects.

Limitations

 Orem’s theory, in general, is viewed as a single whole thing while Orem

defines a system as a single whole thing.
 Orem’s theory is simple yet complex. The use of self-care in multitudes of
terms, such as self-care agency, self-care demand, self-care deficit, self-
care requisites, and universal self-care, can be very confusing to the
reader.
 Orem’s definition of health was confined in three static conditions which
she refers to a “concrete nursing system,” which connotes rigidity.
 Throughout her work, there is limited acknowledgement of the individual’s
emotional needs.
 Health is often viewed as dynamic and ever-changing.
Conclusion

Orem’s theory is relatively simple, but generalizable to apply to a wide variety of

patients. It explains the terms self-care, nursing systems, and self-care deficit
which are very essential to students who plan to start their career in nursing.

Moreover, this theory signifies that all patients want to care for themselves, and
they are able to recover more quickly and holistically by performing their own self-
care as much as they’re able. This theory is particularly used in rehabilitation and
primary care or other settings in which patients are encouraged to be independent.

Though this theory greatly influences every patient’s independence, the definition of
self-care cannot be directly applied to those who need complete care or assistance
with self-care activities such as the infants and the aged.

THEORY OF GOAL ATTAINMENT

 Imogene M. King (1923 – 2007)

Description

The Theory of Goal Attainment states that “Nursing is a process of action, reaction
and interaction by which nurse and client share information about their perception
in a nursing situation” and “a process of human interactions between nurse and
client whereby each perceives the other and the situation, and through
communication, they set goals, explore means, and agree on means to achieve
goals.”

In this definition, the action is a sequence of behaviors involving mental and

physical action, and the reaction is included in the sequence of behaviors described
in action. King states that the goal of a nurse is to help individuals to maintain their
health so they can function in their roles. The domain of the nurse “includes
promoting, maintaining, and restoring health, and caring for the sick, injured and
dying.” The function of a professional nurse is “to interpret information in the
nursing process to plan, implement, and evaluate nursing care.”

Assumptions

King’s personal philosophy about human beings and life influenced her assumptions
related to environment, health, nursing, individuals, and nurse-patient interactions.
King’s conceptual system and Theory of Goal Attainment were “based on an overall
assumption that the focus of nursing is human beings interacting with their
environment, leading to a state of health for individuals, which is an ability to
function in social roles.”

The assumptions are: (1) The focus of nursing is the care of the human being
(patient). (2) The goal of nursing is the health care of both individuals and groups.
(3) Human beings are open systems interacting with their environments constantly.
(4) The nurse and patient communicate information, set goals mutually, and then
act to achieve those goals. This is also the basic assumption of the nursing process.
(5) Patients perceive the world as a complete person making transactions with
individuals and things in the environment. (6) Transaction represents a life
situation in which the perceiver and the thing being perceived are encountered. It
also represents a life situation in which a person enters the situation as an active
participant. Each is changed in the process of these experiences.

Major Concepts and Subconcepts

Nursing
Nursing is a process of action, reaction, and interaction whereby nurse and client
share information about their perceptions in the nursing situation. The nurse and
client share specific goals, problems, and concerns and explore means to achieve a
goal.

Health
Health is a dynamic life experience of a human being, which implies continuous
adjustment to stressors in the internal and external environment through optimum
use of one’s resources to achieve maximum potential for daily living.

Individual
Individuals are social beings who are rational and sentient. Humans communicate
their thoughts, actions, customs, and beliefs through language. Persons exhibit
common characteristics such as the ability to perceive, to think, to feel, to choose
between alternative courses of action, to set goals, to select the means to achieve
goals, and to make decisions.

Environment
Environment is the background for human interactions. It is both external to, and
internal to, the individual.

Action
Action is defined as a sequence of behaviors involving mental and physical action.
The sequence is first mental action to recognize the presenting conditions; then
physical action to begin activities related to those conditions; and finally, mental
action in an effort to exert control over the situation, combined with physical action
seeking to achieve goals.

Reaction

Reaction is not specifically defined but might be considered to be included in the

sequence of behaviors described in action.

Interacting Systems of Theory of Goal Attainment

1. Personal Systems
Each individual is a personal system. King designated an example of a personal
system as a patient or a nurse. King specified the concepts of body image, growth,
and development, perception, self, space, and time in order to comprehend human
beings as persons.
“The self is a composite of thoughts and feelings which constitute a person’s
awareness of his individual existence, his conception of who and what he is. A
person’s self is the sum total of all he can call his. The self includes, among other
things, a system of ideas, attitudes, values, and commitments. The self is a
person’s total subjective environment. It is a distinctive center of experience and
significance. The self constitutes a person’s inner world as distinguished from the
outer world consisting of all other people and things. The self is the individual as
known to the individual. It is that to which we refer when we say “I.”

Growth and development can be defined as the processes in people’s lives

through which they move from a potential for the achievement to the actualization
of self.
King defines body image as the way one perceives both one’s body and others’
reactions to one’s appearance.

Space includes that space exists in all directions, is the same everywhere, and is
defined by the physical area known as “territory” and by the behaviors of those
occupying it.

Time is defined as “a duration between one event and another as uniquely

experienced by each human being; it is the relation of one event to another event.”
King (1986) added learning as a subconcept in the personal system but did not
further define it.

2. Interpersonal Systems

These are formed by human beings interacting. Two interacting individuals form a
dyad; three form a triad, and four or more form small or large groups. As the
number of interacting individuals increases, so does the complexity of the
interactions. Understanding the interpersonal system requires the concepts
of communication, interaction, role, stress, and transaction.

Interactions are defined as the observable behaviors of two or more individuals in

mutual presence.

King (1990) defines communication as “a process whereby information is given

from one person to another either directly in a face-to-face meeting or indirectly
through telephone, television, or the written word.”

King defines transactions as “a process of interactions in which human beings

communicate with the environment to achieve goals that are valued… goal-directed
human behaviors.

The characteristics of the role include reciprocity in that a person may be a giver at
one time and a taker at another time, with a relationship between two or more
individuals who are functioning in two or more roles that learned, social, complex,
and situational.

Stress is “a dynamic state whereby a human being interacts with the environment
to maintain balance for growth, development, and performance, which involves an
exchange of energy and information between the person and the environment for
regulation and control of stressors.”

3. Social Systems

A more comprehensive interacting system consists of groups that make up society,

referred to as the social system. Religious, educational, and health care systems
are examples of social systems. The influential behavior of an extended family on
an individual’s growth and development is another social system example. Within a
social system, the concepts of authority, decision making, organization, power,
and statusguide system understanding.

Power is the capacity to use resources in organizations to achieve goals… is the

process whereby one or more persons influence other persons in a situation… is the
capacity or ability of a person or a group to achieve goals… occurs in all aspects of
life and each person has potential power determined by individual resources and
the environmental forces encountered. Power is a social force that organizes and
maintains society. Power is the ability to use and to mobilize resources to achieve
goals.

Status is “the position of an individual in a group or a group in relation to other

groups in an organization” and is identified that status is accompanied by
“privileges, duties, and obligation.”

Decision making is “a dynamic and systematic process by which goal-directed

choice of perceived alternatives is made and acted upon by individuals or groups to
answer a question and attain a goal” (King, 1990).

King (1986) added control as a subconcept in the social system but did not further
define the concept.

Dynamic Conceptual Systems

The figure above demonstrates the conceptual system that provided “one approach
to studying systems as a whole rather than as isolated parts of a system” and was
“designed to explain the organized wholes within which nurses are expected to
function.”

King has interrelated the concepts of interaction, perception, communication,

transaction, self, role, stress, growth and development, time, and space into a
theory of goal attainment. Her theory deals with a nurse-client dyad, a relationship
to which each person brings personal perceptions of self, role, and personal levels
of growth and development. The nurse and client communicate, first in interaction
and then in transaction, to attain mutually set goals. The relationship takes place in
space identified by their behaviors and occurs in forward-moving time.

She believed that her “framework differs from other conceptual schema in that it is
concerned not with fragmenting human beings and the environment but with
human transactions in different kinds of environments.”

Process of Interaction

The figure above represents a process of human interactions that lead to

transactions: A model of transaction. According to King, “The human process of
interactions formed the basis for designing a model of transactions that depicted
theoretical knowledge used by nurses to help individuals and groups attain goals.”

Interaction

Interaction is a process of perception and communication between person and

environment and between person and person represented by verbal and nonverbal
behaviors that are goal-directed.
Transaction

Transaction is a process of interactions in which human beings communicate with

the environment to achieve goals that are valued; transactions are goal-directed
human behaviors.
Perception is “each person’s representation of reality.”

Communication

Communication is defined as “a process whereby information is given from one

person to another either directly in face-to-face meetings or indirectly through
telephone, television, or the written word.”

Role

Role is defined as “a set of behaviors expected of persons occupying a position in a

social system; rules that define rights and obligations in a position; a relationship
with one or more individuals interacting in specific situations for a purpose.”

Stress

Stress is “a dynamic state whereby a human being interacts with the environment
to maintain balance for growth, development, and performance… an energy
response of an individual to persons, objects, and events called stressors.”

Growth and Development

Growth and development can be defined as the “continuous changes in individuals

at the cellular, molecular, and behavioral levels of activities… the processes that
take place in the life of individuals that help them move from potential capacity for
achievement to self-actualization.”

Time

Time is “a sequence of events moving onward to the future… a continuous flow of

events in successive order that implies a change, a past and a future… a duration
between one event and another as uniquely experienced by each human being…
the relation of one event to another.”

Space

Space exists in every direction and is the same in all directions. Space includes that
physical area called territory. Space is defined by the behaviors of those individuals
who occupy it
Analysis

 The social systems portion of the open systems framework is less clearly
connected to the theory of goal attainment than are the personal and
interpersonal systems.
The citation of the individual being in a social system was not clearly
explained considering that the social system encompasses other concepts
and subconcepts in her theory
The model presents interaction which is dyadic in nature which implies
that its applicability cannot be adapted to unconscious individuals.
 Multitude of views and definition is confusing for the reader. Because of
multiple views on one concept such as what have been discussed in her
concept of power blurs the point that the theorist is trying to relate to the
readers.

Strengths

A major strong point of King’s conceptual system and Theory of Goal Attainment is
the ease with which it can be understood by nurses.

The theory of goal attainment also does describe a logical sequence of events.

For most parts, concepts are concretely defined and illustrated.

King’s definitions are clear and are conceptually derived from research literature.
Her Theory of Goal Attainment presents ten major concepts, and the concepts are
easily understood and derived from research literature, which clearly establishes
King’s work as important for knowledge building in the discipline of nursing.

Weaknesses

Theory of Goal Attainment has been criticized for having limited application in areas
of nursing in which patients are unable to interact competently with the nurse. King
maintained the broad use of the theory in most nursing situations.

Another limitation relates to the lack of development of application of the theory in

providing nursing care to groups, families, or communities.

King’s theory also contains some inconsistencies: (1) She indicates that nurses are
concerned about the health care of groups but concentrates her discussion on
nursing as occurring in a dyadic relationship. (2) King says that the nurse and client
are strangers, yet she speaks of their working together for goal attainment and of
the importance of health maintenance.

Conclusion

King contributed to the advancement of nursing knowledge through the

development of her conceptual system and middle-range Theory of Goal
Attainment. By focusing on the attainment of goals, or outcomes, by nurse-patient
partnerships, King provided a conceptual system and middle-range theory that has
demonstrated its usefulness to nurses. Nurses working in a variety of settings with
patients from around the world continue to use King’s work to improve the quality
of patient care.

NEUMAN’S SYSTEM MODEL

 Betty Neuman (1924 – present)

Three words frequently used in relation to stress are inevitable, painful and
intensifying. It is generally subjective, and can be interpreted as the circumstances
one regards as conceivably threatening and out of their control. A nursing
theory developed by Betty Neuman is based on the person’s relationship to stress,
the response to it, and reconstitution factors that are progressive in nature. The
Neuman Systems Model presents a broad, holistic and system-based method to
nursing that maintains a factor of flexibility. It focuses on the response of the
patient system to actual or potential environmental stressors and the maintenance
of the client system’s stability through primary, secondary, and tertiary nursing
prevention intervention to reduce stressors.

What is the Neuman Systems Model?

Betty Neuman describes the Neuman Systems Model as “a unique, open-system-

based perspective that provides a unifying focus for approaching a wide range of
concerns. A system acts as a boundary for a single client, a group, or even a
number of groups; it can also be defined as a social issue. A client system in
interaction with the environment delineates the domain of nursing concerns.”

The Neuman Systems Model views the client as an open system that responds to
stressors in the environment. The client variables are physiological, psychological,
sociocultural, developmental, and spiritual. The client system consists of a basic or
core structure that is protected by lines of resistance. The usual level of health is
identified as the normal line of defense that is protected by a flexible line of
defense. Stressors are intra-, inter-, and extrapersonal in nature and arise from the
internal, external, and created environments. When stressors break through the
flexible line of defense, the system is invaded and the lines of resistance are
activated and the system is described as moving into illness on a wellness-illness
continuum. If adequate energy is available, the system will be reconstituted with
the normal line of defense restored at, below, or above its previous level.

Assumptions

The following are the assumptions or “accepted truths” made by Neuman’s Systems
Model:

 Each client system is unique, a composite of factors and characteristics

within a given range of responses.
 Many known, unknown, and universal stressors exist. Each differs in its
potential for disturbing a client’s usual stability level or normal line of
defense. The particular interrelationships of client variables at any point in
time can affect the degree to which a client is protected by the flexible line
of defense against possible reaction to stressors.
 Each client/client system has evolved a normal range of responses to the
environment that is referred to as a normal line of defense. The normal
line of defense can be used as a standard from which to measure health
deviation.
 When the flexible line of defense is no longer capable of protecting the
client/client system against an environmental stressor, the stressor breaks
through the normal line of defense.
 The client, whether in a state of wellness or illness, is a dynamic
composite of the interrelationships of the variables. Wellness is on a
continuum of available energy to support the system in an optimal state of
system stability.
 Implicit within each client system are internal resistance factors known as
lines of resistance, which function to stabilize and realign the client to the
usual wellness state.
 Primary prevention relates to general knowledge that is applied in client
assessment and intervention, in identification and reduction or mitigation
of possible or actual risk factors associated with environmental stressors
to prevent possible reaction.
 Secondary prevention relates to symptomatology following a reaction to
stressors, appropriate ranking of intervention priorities, and treatment to
reduce their noxious effects.
 Tertiary prevention relates to the adjustive processes taking place as
reconstitution begins and maintenance factors move the client back in a
circular manner toward primary prevention.
 The client as a system is in dynamic, constant energy exchange with the
environment. (Neuman, 1995)
Major Concepts of Neuman Systems Model

In this section, we will define the nursing metaparadigm and the major concepts in
Betty Neuman’s Neuman Systems Model.

Human being

Human being is viewed as an open system that interacts with both internal and
external environment forces or stressors. The human is in constant change, moving
toward a dynamic state of system stability or toward illness of varying degrees.

Environment

The environment is a vital arena that is germane to the system and its function.
The environment may be viewed as all factors that affect and are affected by the
system. In Neuman Systems Model identifies three relevant environments: (1)
internal, (2) external, and (3) created.

 The internal environment exists within the client system. All forces and
interactive influences that are solely within boundaries of the client system
make up this environment.
 The external environment exists outside the client system.
 The created environment is unconsciously developed and is used by the
client to support protective coping.

Health

In Neuman’s nursing theory, Health is defined as the condition or degree of system

stability and is viewed as a continuum from wellness to illness. When system needs
are met, optimal wellness exists. When needs are not satisfied, illness exists. When
the energy needed to support life is not available, death occurs.

Nursing

The primary concern of nursing is to define the appropriate action in situations that
are stress-related or in relation to possible reactions of the client or client system to
stressors. Nursing interventions are aimed at helping the system adapt or adjust
and to retain, restore, or maintain some degree of stability between and among the
client system variables and environmental stressors with a focus on conserving
energy.

Open System

A system in which there is a continuous flow of input and process, output and
feedback. It is a system of organized complexity, where all elements are in
interaction.
Basic Stricture and Energy Resources

The basic structure, or central core, is made up of those basic survival factors
common to the species. These factors include the system variables, genetic
features, and strengths and weaknesses of the system parts.

Client Variables

Neuman views the individual client holistically and considers the variables
simultaneously and comprehensively.

Flexible line of defense

A protective accordion-like mechanism that surrounds and protects the normal line
of defense from invasion by stressors.

Normal line of defense

An adaptational level of health developed over time and considered normal for a
particular individual client or system; it becomes a standard for wellness-deviance
determination.

Lines of resistance

Protection factors activated when stressors have penetrated the normal line of
defense, causing a reaction synptomatology.

Subconcepts of Neuman Systems Model

Stressors

A stressor is any phenomenon that might penetrate both the flexible and normal
lines of defense, resulting in either a positive or negative outcome.
  Intrapersonal stressors are those that occur within the client system
boundary and correlate with the internal environment.
 Interpersonal stressors occur outside the client system boundary, are
proximal to the system, and have an impact on the system.
 Extrapersonal stressors also occur outside the client system boundaries
but are at a greater distance from the system that are interpersonal
stressors. An example is social policy.

Stability

A state of balance or harmony requiring energy exchanges as the client adequately

copes with stressors to retain, attain, or maintain an optimal level of health thus
preserving system integrity.

Degree of Reaction

The amount of system instability resulting from stressor invasion of the normal line
of defense.

Entropy

A process of energy depletion and disorganization moving the system toward illness
or possible death.

Negentropy

A process of energy conservation that increases organization and complexity,

moving the system toward stability or a higher degree of wellness.

Input/Output

The matter, energy, and information exchanged between the client and
environment that is entering or leaving the system at any point in time.

Reconstitution

The return and maintenance of system stability, following treatment of stressor

reaction, which may result in a higher or lower level of wellness.

Prevention as Intervention

Intervention modes for nursing action and determinants for entry of both client and
nurse into the health care system.
Strengths and Weaknesses

Betty Neuman reports her nursing model was designed for nursing but can be used
by other health disciplines, which both has pros and cons. As a strength, if multiple
health disciplines use the Neuman’s System Model, a consistent approach to client
care would be facilitated. As a con, if the model is useful to a variety of disciplines,
it is not specific to nursing and thus may not differentiate the practice of nursing
from that of other disciplines.

Strengths

 The major strength of the Neuman Systems Model is its flexibility for use
in all areas of nursing – administration, education, and practice.
 Neuman has presented a view of the client that is equally applicable to an
individual, a family, a group, a community, or any other aggregate.
 The Neuman Systems Model, particularly presented in the model diagram,
is logically consistent.
 The emphasis on primary prevention, including health promotion, is
specific to this model.
 Once understood, the Neuman Systems Model is relatively simple, and has
readily acceptable definitions of its components.

Weaknesses

 The major weakness of the model is the need for further clarification of
terms used.
 Interpersonal and extrapersonal stressors need to be more clearly
differentiated.

Analysis

The delineation of Neuman’s three defense lines were not clearly explained. In
reality, the individual resists stressors with internal and external reflexes which
were made complicated with the formulation of different levels of resistance in the
open systems model of Neuman.

Neuman made mention of energy sources in her model as part of the basic
structure. It can be more of help when Neuman has enumerated all sources of
energy that she is pertaining to. With such, new nursing interventions as to the
provision of needed energy of the client can be conceptualized.

The holistic and comprehensive view of the client system is associated with an open
system. Health and illness are presented on a continuum with movement toward
health described as negentropic and toward illness as entropic. Her use of the
concept of entropy is inconsistent with the characteristics of entropy which is
closed, rather than an open system.

ADAPTATION MODEL OF NURSING

 Sister Callista Roy (1939 – present)

The Adaptation Model of Nursing is a prominent nursing theory aiming to

explain or define the provision of nursing science. In her theory, Sister Callista
Roy’s model sees the individual as a set of interrelated systems who strives to
maintain a balance between various stimuli.

The Roy Adaptation Model was first presented in the literature in an article
published in Nursing Outlook in 1970 entitled “Adaptation: A Conceptual Framework
for Nursing.” In the same year, Roy’s Adaptation Model of Nursing was adapted in
Mount St. Mary’s School in Los Angeles, California.

Major Concepts

Person

“Human systems have thinking and feeling capacities, rooted in consciousness and
meaning, by which they adjust effectively to changes in the environment and, in
turn, affect the environment.”

Based on Roy, humans are holistic beings that are in constant interaction with their
environment. Humans use a system of adaptation, both innate and acquired, to
respond to the environmental stimuli they experience. Human systems can be
individuals or groups, such as families, organizations, and the whole global
community.

Environment

“The conditions, circumstances and influences surrounding and affecting the

development and behavior of persons or groups, with particular consideration of the
mutuality of person and health resources that includes focal, contextual and
residual stimuli.”

The environment is defined as conditions, circumstances, and influences that affect

the development and behavior of humans as an adaptive system. The environment
is a stimulus or input that requires a person to adapt. These stimuli can be positive
or negative.
Roy categorized these stimuli as focal, contextual, and residual. Focal stimuli are
that which confronts the human system and requires the most
attention. Contextual stimuli are characterized as the rest of the stimuli that
present with the focal stimuli and contribute to its effect. Residual stimuli are the
additional environmental factors present within the situation, but whose effect is
unclear. This can include previous experience with certain stimuli.

Health

“Health is not freedom from the inevitability of death, disease, unhappiness, and
stress, but the ability to cope with them in a competent way.”

Health is defined as the state where humans can continually adapt to stimuli.
Because illness is a part of life, health is the result of a process where health and
illness can coexist. If a human can continue to adapt holistically, they will be able to
maintain health to reach completeness and unity within themselves. If they cannot
adapt accordingly, the integrity of the person can be affected negatively.

Nursing

“[The goal of nursing is] the promotion of adaptation for individuals and groups in
each of the four adaptive modes, thus contributing to health, quality of life, and
dying with dignity.”

In Adaptation Model, nurses are facilitators of adaptation. They assess the patient’s
behaviors for adaptation, promote positive adaptation by enhancing environment
interactions and helping patients react positively to stimuli. Nurses
eliminate ineffective coping mechanisms and eventually lead to better outcomes.

Adaptation

Adaptation is the “process and outcome whereby thinking and feeling persons as
individuals or in groups use conscious awareness and choice to create human and
environmental integration.”

Internal Processes

Regulator

The regulator subsystem is a person’s physiological coping mechanism. It’s the

body’s attempt to adapt via regulation of our bodily processes, including
neurochemical, and endocrine systems.
Cognator

The cognator subsystem is a person’s mental coping mechanism. A person uses

his brain to cope via self-concept, interdependence, and role function adaptive
modes.

Four Adaptive Modes

The four adaptive modes of the subsystem are how the regulator and cognator
mechanisms are manifested; in other words, they are the external expressions of
the above and internal processes.

Physiological-Physical Mode

Physical and chemical processes involved in the function and activities of living
organisms. These are the actual processes put in motion by the regulator
subsystem.

The basic need of this mode is composed of the needs associated with
oxygenation, nutrition, elimination, activity and rest, and protection. The complex
processes of this mode are associated with the senses, fluid and electrolytes,
neurologic function, and endocrine function.
Self-Concept Group Identity Mode

In this mode, the goal of coping is to have a sense of unity, meaning the
purposefulness in the universe, as well as a sense of identity integrity. This
includes body image and self-ideals.

Role Function Mode

This mode focuses on the primary, secondary and tertiary roles that a person
occupies in society, and knowing where he or she stands as a member of society.

Interdependence Mode

This mode focuses on attaining relational integrity through the giving and receiving
of love, respect and value. This is achieved with effective communication and
relations.

Levels of Adaptation

Integrated Process

The various modes and subsystems meet the needs of the environment. These are
usually stable processes (e.g., breathing, spiritual realization, successful
relationship).

Compensatory Process

The cognator and regulator are challenged by the needs of the environment, but
are working to meet the needs (e.g., grief, starting with a new job, compensatory
breathing).

Compromised Process

The modes and subsystems are not adequately meeting the environmental
challenge (e.g., hypoxia, unresolved loss, abusive relationships).

Analysis

As one of the weaknesses of the theory that application of it is time-consuming,

application of the model to emergency situations requiring quick action is difficult to
complete. The individual might have completed the whole adaptation process
without the benefit of having a complete assessment for thorough nursing
interventions.
Adaptive responses may vary in every individual and may take a longer time
compared to others. Thus, the span of control of nurses may be impeded by the
time of the discharge of the patient.

Unlike Levine, although the latter tackled on adaptation, Roy gave much focus on
the whole adaptive system itself. Each concept was linked with the coping
mechanisms of every individual in the process of adapting.

The nurses’ roles when an individual presents an ineffective response during his or
her adaptation process were not clearly discussed. The main point of the concept
was to promote adaptation but none were stated on how to prevent and resolve
maladaptation.

Strengths

 The Adaptation Model of Callista Roy suggests the influence of multiple

causes in a situation, which is a strength when dealing with multi-faceted
human beings.
 The sequence of concepts in Roy’s model follows logically. In the
presentation of each of the key concepts, there is the recurring idea of
adaptation to maintain integrity. Every concept was operationally defined.
 The concepts of Roy’s model are stated in relatively simple terms.
 A major strength of the model is that it guides nurses to use observation
and interviewing skills in doing an individualized assessment of each
person.The concepts of Roy’s model are applicable within many practice
settings of nursing.

Weaknesses

 Painstaking application of the model requires significant input of time and

effort.
 Roy’s model has many elements, systems, structures and multiple
concepts.

Assumptions

Scientific Assumptions

 Systems of matter and energy progress to higher levels of complex self-

organization.
 Consciousness and meaning are constructive of person and environment
integration.
 Awareness of self and environment is rooted in thinking and feeling.
 Humans by their decisions are accountable for the integration of creative
processes.
  Thinking and feeling mediate human action.
 System relationships include acceptance, protection, and fostering of
interdependence.
 Persons and the earth have common patterns and integral relationships.
 Persons and environment transformations are created in human
consciousness.
 Integration of human and environment meanings results in adaptation.

Philosophical Assumptions

 Persons have mutual relationships with the world and God.

 Human meaning is rooted in the omega point convergence of the
universe.
 God is intimately revealed in the diversity of creation and is the common
destiny of creation.
 Persons use human creative abilities of awareness, enlightenment,
and faith.
 Persons are accountable for the processes of deriving, sustaining, and
transforming the universe.

BEHAVIORAL SYSTEM MODEL

 Dorothy E. Johnson’s (1919 – 1999)

Description

Johnson’s theory defined Nursing as “an external regulatory force which acts to
preserve the organization and integration of the patient’s behaviors at an optimum
level under those conditions in which the behavior constitutes a threat to the
physical or social health, or in which illness is found.”

It also states that “each individual has patterned, purposeful,

repetitive ways of acting that comprises a behavioral system specific
to that individual.”

Goals

Johnson began her work on the model with the premise that nursing was a
profession that made a distinctive contribution to the welfare of society. Thus,
nursing had an explicit goal of action in patient welfare.

The goals of nursing are fourfold, according to the Behavior System Model: (1) To
assist the patient whose behavior is proportional to social demands. (2) To assist
the patient who is able to modify his behavior in ways that it supports biological
imperatives. (3) To assist the patient who is able to benefit to the fullest extent
during illness from the physician’s knowledge and skill. And (4) To assist the patient
whose behavior does not give evidence of unnecessary trauma as a consequence of
illness.

Assumptions

The assumptions made by Johnson’s theory are in three categories: assumptions

about system, assumptions about structure, and assumptions about functions.

Johnson identified several assumptions that are critical to understanding the nature
and operation of the person as a behavioral system: (1) There is “organization,
interaction, interdependency and integration of the parts and elements of behaviors
that go to make up the system.” (2) A system “tends to achieve a balance among
the various forces operating within and upon it, and that man strive continually to
maintain a behavioral system balance and steady state by more or less automatic
adjustments and adaptations to the natural forces occurring on him.” (3) A
behavioral system, which requires and results in some degree of regularity and
constancy in behavior, is essential to man. It is functionally significant because it
serves a useful purpose in social life as well as for the individual. And (4) “System
balance reflects adjustments and adaptations that are successful in some way and
to some degree.”

The four assumptions about structure and function are that: (1) “From the form
the behavior takes and the consequences it achieves can be inferred what ‘drive’
has been stimulated or what ‘goal’ is being sought.” (2) Each individual person has
a “predisposition to act with reference to the goal, in certain ways rather than the
other ways.” This predisposition is called a “set.” (3) Each subsystem has a
repertoire of choices called a “scope of action.” And (4) The individual patient’s
behavior produces an outcome that can be observed.

And lastly, there are three functional requirements for the subsystems.: (1) The
system must be protected from toxic influences with which the system cannot cope.
(2) Each system has to be nurtured through the input of appropriate supplies from
the environment. And (3) The system must be stimulated for use to enhance
growth and prevent stagnation.

Major Concepts

Human Beings

Johnson views human beings as having two major systems: the biological system
and the behavioral system. It is the role of medicine to focus on the biological
system, whereas nursing’s focus is the behavioral system.

The concept of human being was defined as a behavioral system that strives to
make continual adjustments to achieve, maintain, or regain balance to the steady-
state that is adaptation.

Environment

Environment is not directly defined, but it is implied to include all elements of the
surroundings of the human system and includes interior stressors.

Health

Health is seen as the opposite of illness, and Johnson defines it as “some degree of
regularity and constancy in behavior, the behavioral system reflects adjustments
and adaptations that are successful in some way and to some degree… adaptation
is functionally efficient and effective.”

Nursing

Nursing is seen as “an external regulatory force which acts to preserve the
organization and integration of the patient’s behavior at an optimal level under
those conditions in which the behavior constitutes a threat to physical or social
health, or in which illness is found.”
Behavioral system

Man is a system that indicates the state of the system through behaviors.

System

That which functions as a whole by virtue of organized independent interaction of

its parts.

Subsystem

A mini system maintained in relationship to the entire system when it or the

environment is not disturbed.

Subconcepts

Structure

The parts of the system that make up the whole.

Factors outside the system that influence the system’s behavior, but which the
system lacks power to change.

Variables

Boundaries

The point that differentiates the interior of the system from the exterior.

Homeostasis

Process of maintaining stability.

Stability

Balance or steady-state in maintaining balance of behavior within an

acceptable range.

Stressor

A stimulus from the internal or external world that results in stress or instability.
Tension

The system’s adjustment to demands, change or growth, or to actual disruptions.

Instability

State in which the system output of energy depletes the energy needed to maintain
stability.

Set

The predisposition to act. It implies that despite having only a few alternatives from
which to select a behavioral response, the individual will rank those options and
choose the option considered most desirable.

Function

Consequences or purposes of action.

7 Subsystems of the Behavior System Model

Johnson identifies seven subsystems in the Behavioral System Model. They are:

Attachment or affiliative subsystem

Attachment or affiliative subsystem is the “social inclusion intimacy and the

formation and attachment of a strong social bond.” It is probably the most critical
because it forms the basis for all social organization. On a general level, it provides
survival and security. Its consequences are social inclusion, intimacy, and the
formation and maintenance of a strong social bond

Dependency subsystem

Dependency subsystem is the “approval, attention or recognition and physical

assistance.” In the broadest sense, it promotes helping behavior that calls for a
nurturing response. Its consequences are approval, attention or recognition, and
physical assistance. Developmentally, dependency behavior evolves from almost
total dependence on others to a greater degree of dependence on self. A certain
amount of interdependence is essential for the survival of social groups.

Ingestive subsystem

Ingestive subsystem is the “emphasis on the meaning and structures of the social
events surrounding the occasion when the food is eaten.” It should not be seen as
the input and output mechanisms of the system. All subsystems are distinct
subsystems with their own input and output mechanisms. The ingestive subsystem
“has to do with when, how, what, how much, and under what conditions we eat.”

Eliminative subsystem

Eliminative subsystem states that “human cultures have defined different socially
acceptable behaviors for excretion of waste, but the existence of such a pattern
remains different from culture to culture.” It addresses “when, how, and under
what conditions we eliminate.” As with the ingestive subsystem, the social and
psychological factors are viewed as influencing the biological aspects of this
subsystem and may be, at times, in conflict with the eliminative subsystem.

Sexual subsystem

Sexual subsystem is both a biological and social factor that affects behavior. It has
the dual functions of procreation and gratification. Including, but not limited to,
courting and mating, this response system begins with the development of gender
role identity and includes the broad range of sex-role behaviors.

Aggressive subsystem

Aggressive subsystem relates to the behaviors concerning protection and self-

preservation, generating a defense response when there is a threat to life or
territory. Its function is protection and preservation. Society demands that limits be
placed on modes of self-protection and that people and their property be respected
and protected.
Achievement subsystem

Achievement subsystem provokes behavior that tries to control the environment. It

attempts to manipulate the environment. Its function is control or mastery of an
aspect of self or environment to some standard of excellence. Areas of achievement
behavior include intellectual, physical, creative, mechanical, and social skills.

Strengths

Johnson’s theory guides nursing practice, education, and research; generates new
ideas about nursing; and differentiates nursing from other health professions.

It has been used in inpatient, outpatient, and community settings as well as in

nursing administration. It has always been useful to nursing education and has
been used in practice in educational institutions in different parts of the world.

Another advantage of the theory is that Johnson provided a frame of reference for
nurses concerned with specific client behaviors. It can also be generalized across
the lifespan and across cultures.

The theory also has potential for continued utility in nursing to achieve valued
nursing goals.

Weaknesses

The theory is potentially complex because there are a number of possible

interrelationships among the behavioral system, its subsystems, and the
environment. Potential relationships have been explored, but more empirical work
is needed.

Johnson’s work has been used extensively with people who are ill or face the threat
of illness. However, its use with families, groups, and communities is limited.

Though the seven subsystems identified by Johnson are said to be open, linked,
and interrelated, there is a lack of clear definitions for the interrelationships among
them which makes it difficult to view the entire behavioral system as an entity.

The problem involving the interrelationships among the concepts also creates
difficulty in following the logic of Johnson’s work.

Conclusion
Johnson’s Behavioral System Model describes the person as a behavioral system
with seven subsystems: the achievement, attachment-affiliative, aggressive
protective, dependency, ingestive, eliminative, and sexual subsystems. Each
subsystem is interrelated with the others and the environment and specific
structural elements and functions that help maintain the integrity of the behavioral
system.

Through these, the focus of her model is with what the behavior the person is
presenting making the concept more attuned with the psychological aspect of care
in.

When the behavioral system has balance and stability, the individual’s behaviors
will be purposeful, organized, and predictable. Imbalance and instability in the
behavioral system occur when tension and stressors affect the relationship of the
subsystems or the internal and external environments.